Community Awareness Toward Multiple Sclerosis in the Western Region of Saudi Arabia: A Cross-Sectional Study

Objectives: The aim of this study is to assess the awareness level and knowledge about multiple sclerosis (MS) disease among the general population in the Western region of Saudi Arabia. Methods: This study was a community-based cross-sectional descriptive study carried on by an online questionnaire, previously validated in published studies, to all residents in the western region of Saudi Arabia who successfully fulfilled the inclusion and exclusion criteria a total number of 4038. Results: Out of the total number of respondents (n=3,536), the majority 46% (1,625) showed a low level of knowledge, while 31% (1,116) have an average level of knowledge, and 22.5% (795) have a high level of knowledge. Various factors including age, gender and socioeconomic status showed a potential association. Conclusion: This community-based survey showed a low level of knowledge in regard to MS in the Western region of Saudi Arabia. Multiple variables showed potential associations that can be utilized to efficiently direct governmental and non-governmental health organizations' efforts to maximize awareness of this condition to aid early recognition and early treatment in the hope of better outcomes.


Introduction
Multiple sclerosis (MS) is a lifelong condition considered a main and most prevalent inflammatory neurodegenerative disease affecting the central nervous system (CNS) [1][2][3]. MS is considered to be an organ-specific disease with immune-mediated myelin destruction associated with the term autoimmunity, mediated by autoreactive T helper (Th)1 and Th17 cells [4][5][6]. It is affecting more than two million people worldwide and is currently incurable, no medication fully prevents or reverses progressive neurological deterioration [7][8][9][10]. MS patients present with variable signs and symptoms. Different episodes including optic neuritis, and spinal cord syndrome were common that may lead to serious complications, progressive disability, and even death [11].
Multiple epidemiological studies showed a high prevalence of MS in Saudi Arabia and the number of cases continues to rise [1,12]. Further studies are needed to evaluate community-specific risk factors related to increasing prevalence in Saudi Arabia.
Previous studies in Saudi Arabia [13], including several cities such as Riyadh city [14], Qassim region [1], and Taif city [11], have explored the awareness of MS among the general population. As it's a crucial part of early diagnosis and treatment with disease-modifying medications, and in turn improves outcomes. The conclusion of these studies showed a consistent lack of knowledge in these regions. Because of this lack of awareness, we have to expand the studies on the MS level of knowledge within the remaining cities in Saudi Arabia. Given the aforementioned results, we conducted this study to assess the level of awareness and knowledge about MS among the general population in the Western region of Saudi Arabia.

Study design
This study was a community-based cross-sectional descriptive study conducted in the region of Makkah, Kingdom of Saudi Arabia at Umm AlQura University (UQU), 2021 to 2022.

Study population and sampling methodology
The general population resides in the western region of Saudi Arabia. Adults aged 18 years and more who agreed to participate in the study were included. Any healthcare worker, health specialties students, or MS patients who were diagnosed to have MS of all types of all ages and nationalities were excluded. Data were collected through a previously validated online questionnaire in published studies [1,6]. It was formulated in Arabic and English, was completed using Google Documents, and distributed electronically via social media applications. There was a total of 4,038 participants.
The questionnaire covered the following sections: A) The participants' sociodemographic data, including age in years, gender, nationality, residence, education, marital status, total perceived family income per month, occupation and source of information about MS. B) Level of participants' knowledge and awareness about MS. The questionnaire included 15-item, close-ended questions.
Participants were asked to respond to knowledge items as either yes or no. Incorrect responses were given a score of zero, and correct answers were assigned a score of one. Knowledge percentage scores were assigned based on the literature. The knowledge levels had three components, a low level of knowledge for less than 33% of possible correct answers, an average level of knowledge for 33%-65% of possible correct answers, and a high level of knowledge for 66%-100% of possible correct answers.

Data analysis
Data were analyzed by the Statistical Package for Social Sciences (SPSS®) software for Mac, version 26 (IBM Corp., Armonk, NY, USA). For numerical variables analysis, we used the t-test and chi-square test for categorical data analysis. A p<0.05 value was considered statistically significant. Additionally, an adjusted odd ratio with a 95% confidence interval was reported.

Ethical considerations
Ethical approval was provided by the institutional review board (IRB) of UQU (No. HAPO-02-k-012-2021-09-759). Consent was obtained electronically from all participants after the study aims were explained.

Socio-demographics data
The total responses to the questionnaire were 4,038. Of which, 502 were excluded because they did not meet the inclusion criteria, as 164 were healthcare workers, 302 were health specialties students, and 36 of the participants were MS patients who were diagnosed with the disease, the remaining total sample 3,536 were included in the analysis.

Discussion
Recent epidemiological studies showed increasing rates of MS in Saudi Arabia and the number of cases continues to rise, reflecting the advances in diagnostic modalities and easier access to specialized centers [1]. Currently, all forms of MS have disease-modifying therapeutics that alter the course of their disease. Although treatable, MS has a catastrophic personal, social, economic, and psychological sequel. Early diagnosis and implementation of these agents are essential to improve outcomes and minimize disability [15,16]. Community awareness is paramount in such conditions to seek specialized physicians and allow early diagnosis.
Previous epidemiological studies showed a low level of knowledge regarding MS in multiple regions of Saudi Arabia [13]. The current research was conducted to assess the level of awareness of MS among the population of the Western region of Saudi Arabia. The survey was inclusive of all adults above the age of 18, and 43.6% of respondents were from the age group (of 18-25) years, which may reflect easier access to online resources. Most respondents were females (65%), which goes in line with other regional studies within the kingdom [1,11].
Higher percentages of the participants recognized that MS affects the nervous system (75.2%), has different stages (80.5%), has a relation to vitamin D (75.7%), is treatable (64.6%), and disabling ( 71.9%). MS can present in variable presentations, specific symptoms like visual symptoms, paresthesia, and weakness are the most common. 75% of the study, participant were able to identify these symptoms as MS symptoms which is helpful as the relatively mild symptoms and the remitting nature of MS attacks may delay seeking medical care.
We found a significant relationship between the level of awareness and whether they had previously heard about MS with a significant p-value (p=0.003), 65.2% participants had heard about MS previously, and 21.73% considered to have a high level of knowledge. These findings are consistent with the findings of the study among the Saudi population in Taif city [11] and are likely reflecting scientific curiosity toward an uncommon disease with potential fearsome outcomes. Most of the knowledge learnt about MS was obtained from online sources making a great opportunity to spread more organized, regulated, and factual awareness materials. In addition, Arhan et al. [17] found written materials to be an effective and easy-to-implement methods to improve the understanding of a condition for the patient and their family. Multiple approaches including online sources, written materials and community events will certainly improve the understanding of the disease and the overall awareness of the community.
The fact that more than half of the participants had a degree in higher education (59%) did not improve the level of awareness of the community. In addition, we found no significant association between the level of knowledge and sociodemographic data, including age, gender, nationality, level of education, income, or occupation. This was consistent with previous studies, except Al-Batanony et al., where female participants had a higher level of knowledge.
We suggest arranging health education programs and campaigns regarding MS, they are essential for enhancing the community awareness level in order for the early detection and proper management of this serious disease in the hope of better outcomes. As our result showed that most of the knowledge learnt about MS was obtained from online sources therefore utilizing social media and other online channels is important to improve awareness. Further research regarding community awareness of MS is needed to dissect the causes of mis-knowledge on a larger scale inclusive of the entire kingdom to assist the current efforts and maximize its benefits.

Study limitations
We are aware of a few study limitations that should be addressed. The study collected data using an online questionnaire, which may affect its validity if the answers were researched. The population of the Western region of Saudi Arabia is not high enough to represent the population of Saudi Arabia, hence the results cannot be generalized to the rest of the kingdom.